EPISTAXIS

PAULINE DAMIANA
MS/03030/015

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  Definition;bleeding from inside the nose.
 Epistaxis is usually a sign and not a disease.
 It presents as an emergency.
 It is seen in all age groups.

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 BLOOD SUPPLY OF THE NOSE
 The nose is richly supplied by both the internal and
external carotid systems,both on the nasal septum and the
lateral walls.

 Little’s Area-is situated in the anterior inferior part of the

nasal septum just above the vestibule.
 Four arteries ;
 Anterior ethmoidal artery
 Septal branch of superior labial artery
 Septal branch of sphenopalatine artery
 And the greater palatine artery,all anastomose here to
form a vasclular plexus called kiesselbach’s plexus.
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  This area is most exposed to the drying effect
of inspiratory current and to finger nail trauma.
 Most common site for epistaxis in children and
young adults.
 Woodruff’s plexus;plexus of veins situated
inferior to posterior end of the inferior
turbinate.
 It’s the site for posterior epistaxis in adults.

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 Blood supply of lateral walls

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 CAUSES

 Local ,in the nose or nasopharynx

 General
 Idiopathic.

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  Local causes in the nose;
1. Trauma;fingernail trauma,hard blowing of nose,violent
sneeze,intranasal surgery.
2. Infections;Acute-viral rhinitis,acute sinusitis
3. Chronic-all crust forming diseases e.g atrophic
rhinitis,syphilis septal perforation,Tb,rhinospoidiosis.
4. Foreign bodies;living (maggots)or non-living(rhinolith)
5. Neoplasms;benign-haemangioma or
,malignant(carcinoma)
6. Deviated nasal septum.

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  Nasopharynx
1. Adenoiditis
2. Juvenile angiofibroma
3. Malignant tumours

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  General causes ;
 Cardiovascular system;hypertension,arteriosclerosis,mitral stenosis.
 Disorders of blood and blood vessels;aplastic anaemia,leukemia,vit
k deficiency.
 Liver disease;hepatic cirrhosis-deficiency of factors II,VII,IX and X.
 Kidney disease
 Drugs e.g excessive use of salicylates and other
analagesics,anticoagulant therapy
 Mediastinal compression-tumours of medisatinum (raised venous
pressure in the nose)
 Acute infections;influenza,measles,malaria.
 Vicarious menstruation-epistaxis occuring at time of menstruation.

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 Classification
 Anterior epistaxis;when blood flows out from
the front of the nose with the patient in sitting
position.
 Posterior epistaxis;blood flows back into the
throat.patient may swallow it and later have a
coffee coloured vomitus.(haematemesis)

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 management
 It is important to take a detailed history and
examination in order to properly manage the patient.
 One must know;
 Mode of onset ;spontaneous or traumatic
 Duration and frequency of bleeding
 Amount of blood loss
 Side of nose where bleeding is occuring
 Type;anterior or posterior
 Family history
 Drug history.

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 First aid

 90% of bleeding originates from little’s

area.This can be easily controlled by pinching
the nose with thumb and index finger for about
5 minutes.
 This controls the vessels of little’s area.
 Trotter’s method-patient is made to sit,leaning
forward over a basin to spit any blood and
breathe quietly from the mouth.
 Application of cold compresses to cause reflex
vasoconstriction.
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  Cauterization
 Useful in anterior epistaxis when the bleeding
point has been located.
 Silver nitrate cautery-avoid cautery of bilateral
nasal septum as this may lead to necrosi and
perforation of the septum.

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 Anterior nasal packing
 Done when there is profuse bleeding/site of bleeding is
difficult to localize.
 Use ribbon gauze soaked in liquid paraffin.
 About 1m of gauze is needed for each cavity(2.5cm wide in
adults and 12mm in children.
 Few cms of gauze are folded upon itself and inserted along the
floor
 The whole nasal cavity is then packed tightly by layering the
gauze from floor to the roof and from before backwards.
 Packing can also be done in vertical layers from back to front.
 Can be removed after 24h if bleeding has stopped.If not the
pack can be left for 2-3 days.give systemic antibiotics to
prevent sinus infection and toxic shock syndrome.
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 Posterior nasal packing
 For patients bleeding posteriorly into the throat.
1. Three silk ties are tied to a piece of gauze and rolled into the
shape o a cone.
2. A rubber catheter is passed through the nose and its end
brought out from the mouth.
3. Ends of the silk threads are tied to it and the catheter
withdrawn from the nose.
4. Pack,which follows the silk thread,is now guided into the
nasopharynx with the index finger.
5. The anterior nasal cavity is now packed and silk threads tied
over a dental roll.
6. The third silc thread is cut short and allowed to hang in the
oropharynx.Helps with easy removal.
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 Postanasal pack
Postanal pack

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  Patients who require postnasal packs should
always be hospitalized.
 A foley’s catheter (size 12-14 F) can also be used
instead of a postanasal pack
 Posterior ballon packing –easiest method
 After insertion,the ballon is inflated with 5-10 ml
normal saline.
 The bulb is inflated with normal saline and pulled
forward so that the choana is blocked and then the
anterior nasal pack is kept in the usual manner.

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 Other forms of management
 Endoscopic cauterization

 Elevation of mucoperichondrial flap and

submucous resection (SMR)operation.

 Ligation of vessels

 Transnasal endoscopic sphenopalatine artery

ligation.
 Embolization.

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 Hereditary haemorrhagic telangiectasia
 Occurs on the anterior part of nasal septum
and is the cause of recurrent bleeding.
 It can be treated using Argon,KTP laser.
 The procedure may require to be done several
timesa year as it recurs in the sorrounding
mucosa.

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 END

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